AAN: New Advice on Getting Dementia Patients off the Road

Action Points

Explain to interested patients that, according to the American Academy of Neurology's review, determining which patients with mild dementia may safely drive must be handled individually.

Explain that scientific research suggests that patients' and caregivers' beliefs that patients are safe to drive are unreliable.

Explain that scores on a standardized test for dementia, caregivers' assessments that patients may not be safe to drive, and certain aspects of patients' driving history are helpful in identifying patients who should stop driving.

TORONTO -- A dementia rating test and assessments by caregivers can be very useful in identifying people with dementia who need to quit driving, researchers said here.

Patients' own confidence in their driving ability and their fearlessness behind the wheel? Not so useful.

Those were the main messages in new practice guidelines issued by the American Academy of Neurology at its annual meeting here.

Headed by Donald J. Iverson, MD, of the Humboldt Neurological Medical Group in Eureka, Calif., an AAN committee reviewed the literature on driving risk associated with dementia, updating a 10-year-old guideline.

Iverson summarized the findings at a press conference here.

The old AAN guideline indicated that patients with mild dementia "pose a significant traffic safety problem," implying that they should all be kept off the road.

But studies have found that up to 76% of patients with mild dementia can pass an on-road driving test, Iverson indicated. Consequently, a broad recommendation that all patients with mild dementia stop driving is inappropriate.

That leaves clinicians, patients, and families with the difficult challenge of deciding whether a particular individual is too impaired to be allowed to drive.

The researchers found strong evidence that one dementia assessment tool -- the Clinical Dementia Rating scale -- can identify patients at high risk for unsafe driving.

Results with that instrument are the first step in a suggested algorithm included in the published guideline.

Patients with a score of 2.0 or greater are at relatively high risk and should probably surrender the keys, Iverson and colleagues indicated.

Scores of 0.5 to 1.0 should trigger evaluation of additional risk factors, according to the algorithm. (Iverson explained that no score between 1.0 and 2.0 is possible with the scale.)

One of the strongest indicators, the committee found, was when a caregiver rates a patient's driving ability as "marginal or unsafe."

On the other hand, physicians would do well not to believe dementia patients who think they are safe drivers. Strong evidence from multiple studies indicated that high proportions of such drivers failed on-road driving tests.

One study, in fact, found that all patients with mild Alzheimer's disease who failed a driving test "considered themselves to be safe drivers," according to Iverson and colleagues.

Iverson said caregivers' opinions that patients are good drivers are not that helpful either -- it's only when they say the patients are doing poorly behind the wheel that clinicians should include it in an assessment.

Other aspects of patients' driving history -- traffic tickets, crashes, and avoidance of certain situations, such as driving at night or in the rain -- can be helpful in identifying those who should stop driving altogether, he said.

Iverson pointed to one study indicating that an older patient with two recent tickets was in the same risk category as a 16-year-old boy.

But physicians should be wary of relying heavily on driving history in making a judgment, because the underlying studies qualified only for a "level C" rating, indicating that the underlying evidence was relatively weak.

There was no evidence to suggest that lack of so-called situational avoidance indicates a relatively safe driver, the researchers pointed out.

Meanwhile, the science conducted thus far is too sparse to support neuropsychological testing, after controlling for dementia, for predicting driving ability.

Nor are there any proven interventions to increase driving safety for dementia patients. "There was no evidence that interventions were of benefit," Iverson said.

Some that have been tried include licensing restrictions and requiring that older individuals come into motor-vehicle department offices personally to renew licenses or that they have a "copilot" when they drive.

Such strategies may genuinely be beneficial, Iverson said, but currently the scientific proof is lacking.

He also noted that what physicians are required to do with information on patients who may be too impaired to drive varies widely from one state to the next.

For example, in California, physicians must report to the state when a patient has lost the ability to perform just one function of daily living. "If a patient can no longer brush his teeth, a physician must report that to the DMV," he said.

But in other states, he added, laws protecting patient confidentiality hold sway. Physicians can be sued if they share medical information with third parties.

Kostas Lyketsos, MD, of Johns Hopkins University, told MedPage Today and ABC News in an e-mail that it's important for physicians to work with families in evaluating patients whose dementia may be too severe to permit further driving.

"I do not think it is a good idea for this to be left up to caregivers alone, as they often do not have the right experience, and since some have a conflict of interest," he said, pointing out that it may be to a family's advantage if the patient keeps driving.

"We will often refer patients for formal driving evaluations and repeat such evaluations to monitor when they should stop driving," said Lyketsos, who was not involved with the guideline update.

Iverson said patients with early-stage dementia should have their driving abilities evaluated every six months, or more frequently if rapid decline is suspected.

He pointed out that forcing patients to stop driving is one of the most difficult decisions that families must make.

"Loss of autonomy is particularly difficult for people of this generation," he said. Not only did they survive the Great Depression and fight in World War II, they have spent their entire lives in automobiles, Iverson noted.

"To have to face giving up the keys is an admission of their own mortality," he said.

This article was developed in collaboration with ABC News.

No external funds supported development of the guideline.

Some authors of the study reported relationships with commercial entities, including Boehringer Ingelheim, Allergan, BrioMed, Merz Pharmaceuticals, and Abbott.

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